Pain assessment is a neglected area but it should be seen as the fifth vital sign alongside other observations. Failure to identify and treat pain can be construed as torture, argues Felicia Cox
You may be surprised to learn that undergraduate nurses and medical students receive only a proportion of the education about pain and relief of pain that veterinary surgeons receive. Despite pain being the most common reason for patients to visit their GP, less than one per cent of university education focuses on pain (Briggs et al, 2009).
When I ask nurses for a definition of pain almost invariably one will paraphrase Margo McCaffery, a pioneer in pain management in the 1980s and state that “pain is what the patient says it is”.
We need to remember that pain is always a subjective experience and can’t be objectively measured by a clinician using a bedside test. What someone experiences and expresses as pain is a result of their previous history, genetics, gender and a plethora of other variables including culture and the context of that pain. Pain may be acute or chronic with the only difference being the duration. For the purposes of differentiation, chronic pain tends to persist for longer than three months.
Failure to identify commonly occurring acute pain such as that arising from leg ulcer dressings leads to under treatment and can have adverse effects. Acute pain is a warning sign, while uncontrolled acute pain can delay wound healing, increase the risk of venous thromboembolism, affect sleep, induce fear and increase anxiety. I would suggest that undertreated pain implies poor quality of nursing care and that this could be construed as a form of torture.
In 2009, the Chief Medical Officer reported that 7.8 million people in the UK experience pain per annum. Chronic pain such as back pain is associated with increased activity in the spinal cord in response to hyperexcited nerves. This is known as “wind-up” and this may activate the limbic system in the brain which is associated with fear and emotions.
So why do we under treat pain? We need to go back to our individual clinical situations and start with the patient. The patient may have little or no understanding of their pain management. This may result in low expectations of relief from pain, or they may be reluctant to tell you about their pain. Patients may perceive that reporting pain may result in their being seen as a “difficult patient” or they fear that it will result in an increased workload for nurses.
How you as the nurse ask a patient about their pain has a direct impact. Asking: “Do you have any pain?” results in a yes or no answer. An open question such as “Tell me about your pain” will elucidate more useful information. You need to know where the pain is, what it is like, how strong is it, what makes it worse and what makes it better. Pain assessment should not be restricted to when you are undertaking the drug round. Pain should be seen as the fifth vital sign and should be assessed and treated alongside other patient observations. As the patient’s advocate you need to ensure that appropriate medicines - including an appropriate dose and frequency - are prescribed and administered. You also need to assess the effectiveness of any nursing intervention.
The other barrier to effective pain management is the culture of the organisation for which you work. Pain is one of the new Essence of Care Benchmarks. You need to ensure this works towards your patient’s advantage. If you have inadequate resources or restrictive hospital policies ensure that you contribute to benchmark data collection as this will inform the nursing hierarchy of barriers that you face.
The International Association for the Study of Pain (IASP) has designated October 2010 to October 2011 as the Global Year Against Acute Pain. Hopefully this will raise awareness of the need for better pain management. Resources are also readily available to support your nursing practice. Local short courses and free to access online education, such as Change Pain (www.change-pain.co.uk) are available. So what are you waiting for?
FELICIA COX, MSc, RN, is senior nurse, pain management, Royal Brompton & Harefield NHS Foundation Trust; chair of the RCN London Pain Interest Group and a co-opted council member of the British Pain Society
Briggs E et al (2009) Survey of undergraduatepain curricula for healthcare professionals in the United Kingdom: A Short Report. London: British Pain Society.